Provider Demographics
NPI:1124796065
Name:MOES, NICOLE (MA, BCBA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MOES
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 PLUM CREEK DR APT 2N
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-1133
Mailing Address - Country:US
Mailing Address - Phone:219-218-8009
Mailing Address - Fax:
Practice Address - Street 1:5521 W LINCOLN HWY STE 101
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1118
Practice Address - Country:US
Practice Address - Phone:219-359-3272
Practice Address - Fax:219-359-3089
Is Sole Proprietor?:No
Enumeration Date:2021-09-04
Last Update Date:2021-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-21-53013103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst